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DualConnect (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for DualConnect (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on DualConnect (HMO D-SNP) in 2026, please refer to our full plan details page.
DualConnect (HMO D-SNP) is a HMO D-SNP plan offered by SANTA CLARA COUNTY HEALTH AUTHORITY available for enrollment in 2025 to people living in Santa Clara County. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that DualConnect (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
DualConnect (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about DualConnect (HMO D-SNP).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For DualConnect (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $10.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9250.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The DualConnect (HMO D-SNP) plan features an Enhanced Alternative prescription drug benefit with a $615.00 annual deductible, which may be reduced to $10.00 for individuals qualifying for the full Low-Income Subsidy. During the initial coverage phase, you will pay a 25% coinsurance at standard pharmacies for Tier 1 preferred generics, Tier 2 standard generics, Tier 3 preferred brands, and Tier 4 non-preferred drugs. For Tier 5 specialty drugs, there is no copay during this initial phase until your total drug costs reach $2,100.00. Once your yearly out-of-pocket drug costs exceed $2,100.00, you will enter the catastrophic coverage phase. In this final phase, you will pay nothing for your Medicare Part D covered prescriptions.
Additional Benefits
The DualConnect (HMO D-SNP) plan offers essential medical coverage where most primary care, outpatient, emergency, and diagnostic services require a 20% coinsurance and no copay. Inpatient hospital stays and skilled nursing facility care follow Medicare-defined cost-sharing with no copay, while home health services are fully covered with no copay or coinsurance. Most of these core medical benefits require prior authorization and doctor referrals. For supplemental care, the plan features partial vision and dental coverage, including a $200 eyewear allowance every two years, though routine hearing services are excluded. Members can also access a $100 quarterly over-the-counter item allowance and select zero-dollar preventive services.
Inpatient Hospital See details
DualConnect (HMO D-SNP) partially covers inpatient acute and psychiatric hospital services, which require prior authorization and are subject to Original Medicare-defined coinsurance with no copay. Specific exclusions apply, as additional days, non-Medicare-covered stays, and room upgrades are not covered.
Outpatient Services See details
DualConnect (HMO D-SNP) covers outpatient services—including outpatient hospital, ambulatory surgical center, substance abuse, and blood services—with a 20% coinsurance and no copay. Prior authorization and doctor referrals are required for most of these covered services.
Partial Hospitalization See details
Partial hospitalization is covered by DualConnect (HMO D-SNP) with a 20% coinsurance and no copay. Prior authorization and a doctor referral are required to access these services.
Ambulance and Transportation Services See details
DualConnect (HMO D-SNP) covers ground and air ambulance services with a 20% coinsurance and no copay, subject to prior authorization. For transportation services, some services are covered, but transportation to plan-approved and any health-related locations is not covered.
Emergency Services See details
DualConnect (HMO D-SNP) partially covers emergency services, offering covered emergency and urgently needed services with a 20% coinsurance and no copay, though the coinsurance is waived if you are admitted to the hospital within three days. Worldwide emergency coverage, worldwide urgent coverage, and worldwide emergency transportation are not covered under this plan.
Primary Care See details
DualConnect (HMO D-SNP) offers partially covered Primary Care benefits with no copay and a 20% coinsurance for most services. Podiatry services and routine chiropractic care are not covered under this plan.
Preventive Services See details
Preventive services are partially covered by DualConnect (HMO D-SNP) with no copay or coinsurance for zero-dollar preventive services, health education, fitness benefits, and remote access. A 20% coinsurance and no copay apply to kidney disease education and select other screenings, while annual physical exams, in-home safety assessments, and weight management programs are not covered.
Hearing Services See details
DualConnect (HMO D-SNP) does not cover hearing services, as routine hearing exams, hearing aid fittings, prescription hearing aids, and over-the-counter (OTC) hearing aids are all excluded from coverage. Because these services are not covered, there are no plan copays or coinsurance benefits available.
Vision Services See details
DualConnect (HMO D-SNP) partially covers vision services, offering one routine eye exam per year with no copay and a 20% coinsurance. Eyewear is covered up to a $200 maximum limit every two years for contact lenses and complete eyeglasses, but individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by DualConnect (HMO D-SNP), with covered Medicare dental services requiring a 20% coinsurance and no copay. Specific sub-services including restorative, endodontics, periodontics, prosthodontics, implants, orthodontics, maxillofacial prosthetics, adjunctive general, and oral surgery are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by DualConnect (HMO D-SNP) and require prior authorization, offering Medicare Part B chemotherapy, radiation, and other Part B drugs with no copay and 0% to 20% coinsurance. Medicare Part B insulin drugs are also covered under this benefit with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by DualConnect (HMO D-SNP) with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive these services.
Medical Equipment See details
DualConnect (HMO D-SNP) covers medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, with no copay and a 20% coinsurance. Prior authorization is required for these services, and coverage may be limited to preferred vendors or specified manufacturers.
Diagnostic and Radiological Services See details
DualConnect (HMO D-SNP) covers diagnostic and radiological services, including lab tests, therapeutic radiology, and outpatient X-rays, with a 20% coinsurance and no copay. Prior authorization and a doctor referral are required for these covered services.
Home Health Services See details
Home Health Services are covered under the DualConnect (HMO D-SNP) plan with no copay or coinsurance. Members are required to obtain prior authorization and a doctor referral to access these benefits.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the DualConnect (HMO D-SNP) plan, meaning there is no copay or coinsurance for cardiac, intensive cardiac, pulmonary, or SET for PAD rehabilitation services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by DualConnect (HMO D-SNP), requiring prior authorization and a doctor referral but allowing admission with no prior three-day hospital stay. Copays and coinsurance follow Medicare-defined cost-sharing, but additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered under DualConnect (HMO D-SNP), with Over-the-Counter (OTC) items covered up to a maximum benefit of $100 every three months. Acupuncture, Meal Benefits, and Highly Integrated Services are not covered under this plan.
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